Citation Nr: 1004569 Decision Date: 01/29/10 Archive Date: 02/16/10 DOCKET NO. 04-30 247 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Marine Corps League WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD David Traskey, Associate Counsel INTRODUCTION The Veteran had active service from January 1966 to December 1967. He also had service in the Republic of Vietnam and was awarded the Purple Heart Medal among other decorations. This matter came before the Board of Veterans' Appeals (Board) on appeal from decisions of June 2003 and September 2006 by the Department of Veterans Affairs (VA) St. Petersburg, Florida, Regional Office (RO). The Veteran requested a Travel Board hearing in connection with the current claims. The hearing was scheduled and subsequently held in May 2008. The Veteran testified before the undersigned Veterans Law Judge (VLJ) and the hearing transcript is of record. The Veteran's claims were previously before the Board in July 2008 and remanded at that time for additional evidentiary development. The requested development was completed and the Veteran's claims are before the Board for final appellate consideration. FINDINGS OF FACT 1. The Veteran's PTSD is manifested by depressed, constricted affect, dysphoric or sad mood, impaired sleep with nightmares, irritability, social isolation and estrangement, anxiety, sadness, depression, intolerant, aggressive, or argumentative behavior, hyperarousal, avoidant behavior, re-experiencing, difficulty interacting with others, intrusive thoughts, and occasional suicidal or homicidal ideation. 2. The Veteran's PTSD is not manifested by total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. 3. The Veteran is service-connected for PTSD (70 percent disabling); type II diabetes mellitus (20 percent disabling); gunshot wound scars, right humerus with retained foreign body (10 percent disabling); and bilateral hearing loss (non-compensably disabling). The Veteran's combined disability evaluation is 70 percent from March 19, 2003, 100 percent from April 11, 2005, and 80 percent, effective June 1, 2005. 4. Resolving all doubt in the Veteran's favor, his service- connected PTSD is of such severity to preclude him from obtaining or maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 70 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.130, Diagnostic Code 9411 (2009). 2. Resolving all doubt in the Veteran's favor, the criteria for entitlement to a total disability rating based on individual unemployability due to a service-connected disability are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. PTSD The Veteran in this case contends that he is entitled to a higher initial disability evaluation for his service- connected PTSD. The Veteran was originally granted service connection for PTSD in the June 2003 rating decision currently on appeal. The RO evaluated the Veteran's psychiatric disability as 50 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code 9411, effective March 19, 2003. A subsequent rating decision dated August 2007 increased the Veteran's disability evaluation to 70 percent under Diagnostic Code 9411, effective March 19, 2003. Upon the Veteran's request, he was also given a temporary total rating (100 percent), effective April 11, 2005, after he was hospitalized for psychiatric treatment. Thereafter, the Veteran's disability evaluation for PTSD was 70 percent disabling, effective June 1, 2005. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred in or aggravated by military service and the residual conditions in civilian occupations. 38 U.S.C.A.§ 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2009). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2009). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the Veteran's claim is to be considered. In initial ratings cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2009). The Board has considered staged ratings in this case, but, as will be further discussed below, the evidence does not show a variance in the signs and symptoms of the Veteran's service-connected PTSD during the claim period such that staged ratings are for application in this case. Generally, "pyramiding," the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided. 38 C.F.R. § 4.14 (2009). A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. When evaluating a mental disorder, consideration shall be given to the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation will be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. It is the responsibility of the rating specialist to interpret examination reports in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. §§ 4.2, 4.126 (2009). Global assessment of functioning (GAF) scores, which reflect the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health, are also useful indicators of the severity of a mental disorder. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). GAF scores ranging between 71 to 80 reflect symptoms, if present, that are a transient and expectable reaction to psychosocial stressors (e.g., difficulty concentrating after family argument), no more than slight impairment in social, occupational, or school functioning (e.g. temporarily falling behind in schoolwork). GAF scores ranging between 61 to 70 reflect mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally indicate that the individual is functioning pretty well, and has some meaningful interpersonal relationships. Scores between 51 to 60 are indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores between 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Scores between 31 to 40 indicate impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). GAF scores between 21 to 30 indicate that behavior is considerably influenced by delusions or hallucinations or reflect serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or an inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends). Under the provisions of 38 C.F.R. § 4.130 (2009), a 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, including work, school, family relationships, judgment, thinking or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is not warranted unless there is total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. Id. Use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each Veteran and disorder, and the effect of those symptoms on the Veteran's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Service treatment records (STRs) associated with the claims file are negative for a diagnosis of or treatment for any psychiatric abnormalities, to include PTSD. The Board notes, however, that the Veteran sustained a shrapnel wound to the right forearm in September 1967 during service in the Republic of Vietnam. The Veteran was subsequently awarded the Purple Heart Medal as a result of this incident. The Veteran sought VA psychiatric care in March 2003 after reporting subjective symptoms of depressed mood, poor motivation, decreased interest in activities, nightmares and passive thoughts of suicide. Following a mental status examination, the Veteran's GAF score was 50. The impression was delayed onset, combat-related PTSD. The examiner also diagnosed the Veteran as having dysthymia. The Veteran sought additional VA psychiatric care in March 2003 after reporting subjective symptoms of anxiety, insomnia, depression, intrusive thoughts, recurrent dreams and flashbacks, as well as occasional suicidal thoughts. A mental status examination revealed that the Veteran was alert and oriented, but he had a depressed, constricted affect and dysphoric mood. The Veteran was noted to have good eye contact with relevant, goal-directed speech. No evidence of suicidal thoughts, delusions, obsessions, phobias, psychomotor agitation or retardation, or comprehension, attention, judgment, or memory impairments were found. The Veteran's GAF score was 50. The impression was severe, prolonged, delayed PTSD. The Veteran submitted a statement in support of the current claim dated April 2003. Specifically, the Veteran indicated that his "nervous condition" was manifested by insomnia, nightmares, flashbacks, tiredness, lack of interest in activities, and severe depression. The Veteran also described himself as "short-tempered" and indicated that he sold his business because "I could not handle that stress." The Veteran was afforded a VA Compensation and Pension (C&P) examination in June 2003. The examiner noted that the Veteran's past medical history was significant for PTSD. It was also noted that the Veteran took 20 milligrams (mg) of Paxil for this condition. The Veteran also stated that he worked for his wife's business, Minuteman Press, for the past 17 years. Over the previous three years, however, the Veteran encountered difficulty working on a regular basis due to his increasing psychiatric symptomatology. After his wife sold this business, the Veteran remained employed there for a period of approximately nine months, but the Veteran indicated that he was looking for another job. He was employed at the time of the examination. It was also noted that the Veteran was married twice, with the first marriage ending in divorce. The Veteran had two children from this first marriage, but had not spoken to them in 20 years. The Veteran reported subjective complaints of impaired sleep with nightmares, intrusive memories, weight loss, anger, irritability, social isolation, nervousness, exaggerated startle response, poor motivation, and survivor's guilt. A mental status examination found the Veteran to be prompt, casually dressed, and well-groomed. His mood was somber, depressed, and anxious. No evidence of speech or thought abnormalities, hallucinations, or suicidal or homicidal ideation was found. The Veteran did, however, admit to one suicide attempt in the past. His insight and judgment were described as "good." The Veteran's GAF score was 52. The impression was delayed onset PTSD and dysthymic disorder. The examiner further indicated that the Veteran's GAF score reflected moderate to serious symptoms of PTSD and depression which affected his psychological well-being as well as his social and occupational functioning. The Veteran was found to be competent to manage his financial affairs. The Veteran presented to a VA psychiatric clinic in September 2003 after losing his job. According to the Veteran, he lost his job following a non-physical confrontation with his boss. The Veteran also reported continued nightmares, intrusive thoughts, impaired sleep, irritability, exaggerated startle response, depression, and anxiety. A mental status examination found the Veteran to be alert and oriented (times three), neat, pleasant, calm, and casually dressed. The Veteran's affect was appropriate to content of thought and mood. The Veteran's mood, however, was noted to be dysphoric and depressed, but without evidence of suicidal ideation. The Veteran's speech was relevant and goal-directed without evidence of hallucinations or delusions. His attention, comprehension, concentration, memory, and judgment were grossly intact. The Veteran returned for additional VA care in March 2004. A mental status examination revealed that the Veteran was appropriately dressed and oriented (times four). He was attentive and cooperative with normal speech, thought processes, and thought content, an anxious mood, and restricted affect. The Veteran's GAF score was 48. The impression was chronic PTSD and panic disorder. Also associated with the claims file are treatment notes from a Vet Center which were received by VA in August 2004. In particular, the Veteran reported subjective symptoms of interpersonal conflict (i.e., divorced, estranged from children for 20 years), social isolation, thoughts of self- harm, sleep disturbance, nightmares, hypervigilance, intrusive recollections, exaggerated startle response, and decreased interest in activities. The impression was PTSD. The Veteran sought additional VA psychiatric care in December 2004. A mental status examination revealed that the Veteran was appropriately dressed and oriented (times four). He was attentive and cooperative with normal speech, thought processes, and thought content, a depressed mood, and restricted affect. The Veteran's GAF score was 48. The impression was chronic PTSD. The Veteran received inpatient psychiatric care at a VA medical facility in March 2005 after reporting homicidal thoughts. In particular, it was noted that the Veteran recently got into a physical altercation with his neighbor. Upon admission, the Veteran was appropriately dressed, attentive, cooperative, and oriented (times four). The Veteran's speech was normal, but his mood was sad and his affect was restricted. His thought content was positive for homicidal ideation. The Veteran's GAF score was 25. The impression was chronic PTSD. Upon discharge, the Veteran's GAF score was 65. The impression was PTSD. The Veteran was re-admitted for additional inpatient psychiatric care in April 2005. A mental status examination conducted at the time of admission indicated that the Veteran was depressed and irritable. He admitted suicidal ideation without plan. No evidence of homicidal ideation or thought disorder was found. His insight was limited. The Veteran also reported problems with his memory. The Veteran's highest GAF score over the past year was assessed as 48. Upon discharge, the Veteran's GAF score was 50 and the impression was chronic PTSD, among other conditions. A follow-up VA treatment note dated May 2005 found the Veteran to be clean and appropriately groomed. He was cooperative, oriented (times four), and participated in a group therapy discussion. His mood was anxious and his affect was restricted. However, the Veteran was noted to have coherent, fluent, and normal speech with goal-directed and appropriate thought processes and content. No evidence of delusions, hallucinations, or suicidal or homicidal ideation was found. The Veteran's concentration was adequate, and his memory, fund of knowledge, and judgment were described as intact or normal although it was noted that his memory was not assessed. The Veteran's insight and judgment were fair. The impression was PTSD. VA administered another C&P PTSD examination in August 2005. It was noted at that time that the Veteran was married to his second wife and that he had no contact with his children from a prior marriage. The Veteran indicated that he was able to care for himself, perform activities of daily living (ADLs), and do "most" of the household chores, including cleaning, laundry, and lawn care. The Veteran stated that he had not worked since 2003 and that he rarely socialized with others. The Veteran reported subjective complaints of continued anxiety and depression. He also reported anger management problems, frequent intrusive thoughts, poor sleep, nightmares, intolerant behavior, and social isolation. A mental status examination revealed the Veteran to be alert, oriented (times four), and cooperative. The Veteran was casually dressed and well-groomed, but wore a stained shirt. His thought processes were logical and goal- oriented, while his speech was coherent and spontaneous. The Veteran's mood was described as "somewhat anxious and depressed," and his affect was congruent, appropriate, and "somewhat constricted." The Veteran admitted to ongoing suicidal ideation, but denied suicidal or homicidal plan or intent. No evidence of thought disorder or inappropriate behavior was found. The Veteran's memory was noted to be intact and his insight and judgment were adequate. The GAF score was 50 and the impression was PTSD and alcohol abuse, continuous. The Veteran was also found competent to manage his financial affairs. The Veteran was afforded a VA C&P examination in July 2006 for the purpose of assessing entitlement to individual unemployability. The Veteran indicated at the time of the examination that he worked in heating systems repair prior to moving to Florida. He also worked for his wife at her printing business. The Veteran remained at the business after she sold it and he worked briefly with the new owner. He left this job in 2002 because he was unable to get along with the new owner. The Veteran also stated that he preferred to be at home because he did not like interacting with people. The VA examiner opined that the Veteran was able to do light duty and moderately physically demanding work. However, the examiner determined that the Veteran was unable to do work that required "a lot" of physical demands or heavy duty-type work as a result of his service-related and non-service related medical conditions. A VA social work note dated July 2006 indicated that the Veteran participated in a group therapy session and depression support group. His GAF score at that time was 50 and the impression was chronic PTSD with delayed onset. The Veteran also underwent another VA C&P PTSD examination in August 2006. In particular, the Veteran indicated that his PTSD symptoms remained largely the same since the last VA examination. The Veteran last worked in 2003, but preferred to spend most of his time alone. He was able to perform ADLs, but reported subjective symptoms of re- experiencing of traumatic events, persistent avoidance of stimuli associated with trauma, numbing of general responsiveness, persistent symptoms of increased arousal, and distressing dreams. A mental status examination found the Veteran to be alert, oriented, and appropriately groomed. The Veteran had good eye contact and no evidence of psychomotor agitation or retardation, or impaired thought processes or communication was found. His speech was of normal rate, tone, and volume, and his mood was euthymic with full and congruent affect. The Veteran's thought content was linear and goal-directed without looseness of association or flight of ideas. The Veteran denied hallucinations as well as suicidal and homicidal ideation, intent, or plan. The Veteran's cognition, insight, and judgment were intact. The GAF score was 50 and the impression was PTSD and alcohol abuse, continuous. The examiner also indicated that the Veteran's symptoms (i.e., hyperarousal, avoidance, re-experiencing, and irritability) appeared unchanged since the previous examination. These symptoms, according to the examiner, resulted in moderate social and occupational dysfunction. The Veteran was competent to manage his VA benefits. In a follow-up VA social work note dated August 2006, the Veteran discussed his reluctance to return to work. He also discussed his lifestyle and the state of his marriage. It was noted that "after several minutes of talking, the vet admitted that he can work and he can apply himself to a job." It was also noted that the Veteran was going for a job interview as a pressman at a local printing company. The Veteran's GAF score was 70. The impression was chronic PTSD with delayed onset. Another follow-up VA social work note dated September 2006 found that the Veteran's job was going "well," although he reported a sense of doom, possibly as a reaction to the pressure of his new job. The GAF score at that time was 60. The impression was chronic PTSD with delayed onset anxiety. The Veteran returned to a VA social worker in October 2006 to report that he was "excited" about his ability to use the presses at work and fine tune them on his own. The social worker described the Veteran as "upbeat and happy," and according to the Veteran, he was looking for a new position that would afford him more hours of work. Upon mental status examination, the Veteran was alert, oriented, and appropriately groomed. The Veteran had good eye contact and no evidence of psychomotor agitation or retardation, or impaired thought processes or communication was found. His speech was of normal rate, tone, and volume, and his mood was euthymic with full and congruent affect. The Veteran's thought content was linear and goal-directed without looseness of association or flight of ideas. The Veteran denied hallucinations as well as suicidal and homicidal ideation, intent, or plan. The Veteran's cognition, insight, and judgment were intact. The GAF score was 65 and the impression was chronic PTSD with delayed onset anxiety. The social worker also diagnosed the Veteran as having alcohol and nicotine dependence, continuous. A follow-up VA social work note dated December 2006 revealed that the Veteran continued to enjoy his job. His GAF score at that time was 70. The Veteran returned for additional VA care in April 2007. According to the examiner, the Veteran recently changed jobs, but appeared to be enjoying his work and his home life. He also expressed a desire to get more involved in the printing profession. Upon mental status examination, the Veteran was alert, oriented, and appropriately groomed. The Veteran had good eye contact and no evidence of psychomotor agitation or retardation, or impaired thought processes or communication was found. His speech was of normal rate, tone, and volume, and his mood was euthymic with full and congruent affect. The Veteran's thought content was linear and goal-directed without looseness of association or flight of ideas. The Veteran denied hallucinations as well as suicidal and homicidal ideation, intent, or plan. The Veteran's cognition, insight, and judgment were intact. The GAF score was 75 and the impression was chronic PTSD with delayed onset anxiety. The social worker also diagnosed the Veteran as having alcohol and nicotine dependence, continuous. The Veteran was diagnosed as having PTSD and major depression in a June 2007 VA psychiatric treatment note after reporting a host of symptoms, including suicidal ideation. According to the examiner, the Veteran exhibited "prominent" signs of PTSD and depression. The examiner also noted that the Veteran continued to do poorly, at least in part because of his alcohol intake. Nevertheless, the examiner concluded that the Veteran deserved "more aggressive treatment of his depression." To this end, the examiner adjusted the Veteran's psychiatric medication with the hope that it would provide "a good antidepressant effect." The Veteran sought additional VA psychiatric care in August 2007. In particular, the Veteran reported thoughts of hurting himself since the 1970s, as well as symptoms of irritability, violent thoughts, social isolation, and avoidant behavior. The examiner noted that the Veteran lived with his wife, but that he was estranged from his children for over 20 years. As for the Veteran's occupational history, it was noted that the Veteran worked for a utility company in the past and that he occasionally helped at his wife's printing company. The examiner also noted that the Veteran had "financial problems." Upon mental status examination, the Veteran was found to be alert, oriented, and adequately groomed. The Veteran's affect was described as constricted and his mood was mildly anxious with an intermittent stare and hypervigilance. His speech was normal in rate and production, well-organized, and spontaneous. The Veteran admitted to suicidal thoughts, but denied action. No evidence of homicidal ideation was found. The Veteran's insight and judgment were "good," and his cognition was likewise grossly normal. The Veteran's GAF score was 50. The impression was PTSD and history of polysubstance abuse. In a December 2007 addendum, the examiner indicated that in her opinion, the Veteran was "incapable of employment due to psychiatric disability from PTSD symptoms as indicated in progress note." The Veteran requested a follow-up VA psychiatric appointment in January 2008. A notation on the examination report indicated that the Veteran lost his job in August 2007. The Veteran's GAF score was 50. In October 2007, the Veteran was found to be eligible for VA Vocational Rehabilitation and Education (VRE) training. He was noted on a VRE assessment to be a high school graduate with a valid driver's license. The Veteran indicated at that time that he felt he was incapable of handling work outside of the house, but that he last worked in August 2007 as a pressman at a print shop. The Veteran's past medical history was significant for PTSD, among other conditions, and the Veteran reported difficulty being around other people. He also self-reported problems with memory, concentration, reasoning, problem solving, and frustration tolerance. These shortcomings, in turn, resulted in irritability, depression, withdrawal, anxiety, aggression, verbal outbursts, and reduced ability to deal with people. According to the examiner, the Veteran's PTSD (along with the other service-connected disabilities) impaired the Veteran's ability to work. The service-connected PTSD, in particular, resulted in difficulty interacting with others, crowd avoidance, flashbacks, and difficulty sleeping. The examiner further concluded that the Veteran's PTSD, among other service-connected disabilities, impaired the Veteran's ability to prepare for, obtain, or retain employment consistent with his abilities, aptitudes, and interests. Moreover, the examiner noted that the Veteran possessed "marginal" skills for direct employment. He also lacked post-high school education and/or training which resulted in the Veteran's inability to qualify for suitable stable employment. Although the Veteran was at one time employed in the heating and air conditioning and graphic design businesses, the examiner pointed out that the Veteran lacked significant "transferable skills." Additionally, the Veteran's skills in the heating and air conditioning business were outdated (and would require re-training), while the labor market did not permit the Veteran to continue with graphic design. In February 2008, the Veteran's VRE case was contracted out for vocational testing and exploration. While working with the contractor, it was noted that the Veteran changed his mind and elected not to pursue VRE services. The Veteran was afforded a period of 30 days to change his mind, but did not do so during this time period. As such, the Veteran's case was closed for "failure to pursue" and he was provided notice of his appellate rights. Associated with the Veteran's claims file is a statement dated March 2008 from one of the Veteran's former employers, The Print Shop. A representative from the company indicated that the Veteran last worked in August 2007 and that he was laid off. The reason for this personnel action was not disclosed, but the representative stated that "we have no record of this person every [sic] paying into a disability fund or receiving any disability payments. . . ." VA requests for information regarding the Veteran's employment history from another employer, Creative Printing, went unanswered. The Veteran sought additional VA psychiatric care in April 2008 after reportedly having a "bad month." Specifically, the Veteran reported increased nightmares and reclusive behavior, particularly after his former wife sent him some pictures and his Purple Heart Medal from Vietnam. The Veteran also indicated that he attempted to keep busy with woodworking projects. Following a mental status examination, the Veteran's GAF score was 49. The impression was PTSD and history of polysubstance abuse. Also associated with the claims file are records pertaining to the Veteran's application and eventual receipt of Social Security Disability benefits. The Veteran alleged entitlement to these benefits on the basis of PTSD, among other conditions. However, it was noted in an April 2008 evaluation that the Veteran had a high school education and that he worked previously as a bindery worker and printing press operator. The examiner described the Veteran's psychiatric disorder as "non-severe" and found that he was able to perform work as a bindery worker and printing press operator. Accordingly, the Veteran was not found to be "disabled" for Social Security Disability purposes at that time. However, the Veteran was subsequently awarded Social Security Disability benefits. The Veteran testified before the undersigned VLJ in May 2008. The Veteran described himself as "a hermit" and stated that his wife helped him take his medication since he was unable to "keep track of them anymore." The Veteran also related having symptoms of social isolation. In particular, the Veteran stated that he had not seen his children in over 20 years and that he rarely left the house except to go to appointments at a VA medical facility. The Veteran also got in a fight with his neighbor and indicated that he worked outside of his house for two out of the last 20 years. At one time, the Veteran's wife owned a printing company for which he did some work, but she usually let him work from home or in a secluded location during that time. He worked in the same industry after his wife sold the business, but his employment with other companies was short- lived. The Veteran allegedly worked for the first company for approximately six months and quit because "I just didn't like the people. I felt they were being very unfair. I just, I couldn't work for them." The Veteran secured employment about two weeks after quitting the first company, but was laid off for an unknown reason approximately six months later. The Veteran further testified that he had not worked since being laid off, but that he went to "VA [vocational] rehabilitation" only to be told "there was nothing they could do for me." Additionally, he testified that he had difficulty in dealing with people, particularly those in authority positions. The Veteran stated that he would "throw things around" at work, but he denied engaging in physical violence. The Veteran also stated that he felt "threatened" by other people, and that he preferred to work alone. The Veteran last worked in August 2007. Additional VA psychiatric treatment records dated May 2008 found slight improvement in the Veteran's symptoms. In particular, he stated that his bouts of irritability and anxiety were under better control. The Veteran also indicated that his depressive episodes were becoming less frequent and that he felt better when involved with home projects such as woodworking. Moreover, the Veteran stated that he no longer felt that weekly appointments were necessary. The Veteran's GAF scores were 55 and 49, respectively, and the impression was chronic PTSD. See also, July and August 2008 VA psychiatric treatment notes. The Veteran was also afforded another VA C&P PTSD examination in December 2008. He reported having the same symptoms for "years," and stated that he stayed home and took care of it. With regard to symptoms, the Veteran reported intermittent nightmares, hypervigilant behavior, agoraphobia, anxiety, and social isolation. Notably, the Veteran reported that he went to VA medical appointments, and occasionally, to Home Depot late at night, or to his brother's house (twice yearly). Following a mental status examination, the examiner concluded that the Veteran continued to endorse symptoms consistent with PTSD (i.e., persistent re-experiencing, flashbacks, and social isolation, hyperarousal, irritability, impaired sleep, and nightmares), but that his condition did not appear to have gotten worse since the previous VA examination in August 2006. In support of this conclusion, the examiner noted that the Veteran self-reported feeling and doing much better with the help of prescribed medications. His attention, recall and language was impaired, however, his thought process and ability to communicate was not impaired. His impulse control was fair. The examiner opined that the Veteran's symptoms may be exacerbated by chronic, daily use of alcohol. However, in light of the Veteran's supportive spouse and access to the Internet, the examiner noted that the Veteran was at least able to partially adjust to impairments he might experience as a result of triggers. To this end, the examiner further concluded that the Veteran had no serious functional impairments of daily life resulting from the service- connected PTSD which would preclude him from obtaining and maintaining gainful employment. In March 2009, the Veteran also underwent a VA examination to determine the impact of his service-connected diabetes mellitus and shell-fragment wound on his ability to obtain and maintain substantially gainful employment. The examiner concluded that neither the Veteran's diabetes mellitus nor his shell-fragment wound would preclude the ability to obtain and maintain substantially gainful employment. In support of this conclusion, the examiner noted that the Veteran's diabetes mellitus, without complications, was an essentially asymptomatic disorder, while the shell-fragment wound residuals did not result in significant neuromuscular dysfunction. Given the evidence of record, the Board finds that the preponderance of the evidence is against an initial evaluation in excess of 70 percent for the Veteran's PTSD. The Veteran's GAF scores during this period ranged from 25 to 75. Such scores reflect a wide variation in psychosocial functioning from transient symptoms and expectable reactions to psychosocial stressors (no more than slight impairment in social or occupational functioning) to serious impairment in communication or judgment with major impairment in social or occupational functioning. The predominant GAF scores during the appeal period, however, ranged from 48 to 55. These scores reflect moderate to serious symptoms. See DSM-IV, supra. As such, the Board finds that the overall disability picture for the period of time covered by the appeal more nearly approximates the criteria for an initial evaluation of 70 percent, but not higher. The Veteran has provided evidence in support of his claim for a higher initial evaluation to show that he has multiple symptoms of PTSD, including impaired sleep with nightmares, difficulty reasoning, irritability, an exaggerated startle response, social isolation and estrangement, anxiety, sadness, depression, weight loss, financial problems, intolerant, aggressive, or argumentative behavior, poor concentration, memory, and motivation, decreased interest in activities, difficulty working with others, avoidant behavior, hypervigilance, intrusive thoughts with flashbacks, nervousness, survivor's guilt, and occasional suicidal or homicidal ideation. In addition, the objective medical evidence of record showed that the Veteran's PTSD is manifested by depressed, constricted affect, dysphoric or sad mood, impaired sleep with nightmares, irritability, social isolation and estrangement, anxiety, sadness, depression, intolerant, aggressive, or argumentative behavior, hyperarousal, avoidant behavior, re-experiencing, difficulty interacting with others, intrusive thoughts, and occasional suicidal or homicidal ideation. See VA records dated March and June 2003, March and December 2004, March, April, and August 2005, July and August 2006, August and October 2007, and February, May, and December 2008. The Board also notes that the Veteran's PTSD symptoms were routinely described as chronic, moderate, and/or severe. See VA records dated March 2003, March and December 2004, March and April 2005, August and October 2006, and May 2008. The Veteran is not, however, entitled to a 100 percent evaluation based on the evidence of record for any period of time covered by this appeal. Namely, there is no evidence of record demonstrating total occupational and social impairment due to gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. On the contrary, VA records associated with the claims file consistently indicated that the Veteran was clean, appropriately groomed, and cooperative without impaired thought processes or communication. The Veteran's thought content was linear and goal-directed without looseness of association or flight of ideas. He also routinely denied having any delusions and hallucinations, and was able to perform ADLs although he has reported that he should bathe more often than he does. However, this does not more nearly approximate an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene). Moreover, while the evidence does show that he has problems with impulse control, the evidence does not show that there is a persistent danger of hurting himself or others. The incident where he hit his neighbor was precipitated by a dog bite from his neighbor's pet and there is no showing that he has hurt anyone since that incident. While he did have a verbal altercation with an employer and punched a hole in a wall of his house, these two incidents over the span of many years does not more nearly approximate a showing that he is a persistent danger to others. Moreover, the evidence does not show that he is disoriented to time or place. The evidence consistently shows that he is in fact oriented to time and place. In addition, while the Veteran has reported problems with memory loss and he did have trouble with recall on an examination, there is no showing that he has memory loss related to the names of close relatives, his occupation or his own name. The Veteran reported occasional suicidal ideation with plan (i.e., carbon monoxide poisoning) as well as occasional homicidal ideation with plan (i.e., shooting neighbor). VA treatment records associated with the claims file also revealed some difficulty with impaired impulse control (hitting his neighbor) as well as difficulty establishing and maintaining effective relationships, especially with his children. These symptoms were considered in the assignment of the Veteran's initial 70 percent evaluation. However, as noted above, these symptoms alone are insufficient to warrant a 100 percent evaluation. Thus, the Veteran is not entitled to a 100 percent evaluation for any period of time covered by this appeal. The Board also notes that the Veteran has been diagnosed as having psychiatric conditions in addition to the service- connected PTSD. As the symptoms attributable to other psychiatric conditions have not been clearly disassociated from his PTSD, the Board considered all psychiatric symptoms in reaching the above conclusions. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). There is also no evidence that the manifestations of the Veteran's service-connected PTSD are unusual or exceptional to demonstrate that the rating schedule is inadequate for determining the proper level of disability. Furthermore, as there is no indication in the record as to why the Veteran's case is not appropriately rated under the schedular criteria, extraschedular consideration is not warranted in this case, particularly where, as here, the signs and symptoms of the Veteran's service-connected PTSD are addressed by the relevant criteria as discussed above. In this regard, it is also pointed out that the assignment of an initial 70 percent evaluation, along with a temporary total evaluation following hospitalization for psychiatric treatment, shows that the Veteran has functional impairment that is significant. The currently assigned rating also contemplates that there is commensurate industrial impairment as a result of the Veteran's service-connected PTSD. See also, 38 C.F.R. § 4.1 (2009) (noting that the percentage ratings represent as far as can be practically determined the average impairment in earning capacity resulting from service-related diseases and injuries and their residual conditions in civilian occupations). The Board is aware that the Veteran was laid off on more than one occasion during the pendency of this appeal and that at least on one occasion, such action resulted from a non-physical confrontation with his boss. For reasons discussed in greater detail below, the Board finds that the preponderance of the evidence supports a finding of a total disability rating based on individual unemployability. Moreover, while the Veteran was hospitalized for his PTSD, there is no evidence of frequent periods of hospitalization for psychiatric care. Therefore, the Board finds that the criteria for submission for an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Thun v. Peake, 22 Vet. App 111, 115-16 (2008); see also Bagwell v. Brown, 9 Vet. App. 237 (1996). II. TDIU The Veteran also asserts that he is entitled to a total disability evaluation based on individual unemployability (TDIU). Regulations provide that a total disability rating based on individual unemployability is warranted when the evidence shows that the Veteran is precluded from obtaining or maintaining substantially gainful employment by reason of his service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2009). VA defined substantially gainful employment as "employment at which non-disabled individuals earn their livelihood with earnings comparable to the particular occupation in the community where the veteran resides." See M21-MR, Part IV, Subpart ii, Chapter 2(F)(24)(d). Consideration may be given to the Veteran's level of education, special training, and previous work experience when arriving at this conclusion, but factors such as age or impairment caused by non-service-connected disabilities are not to be considered. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2009); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Board notes that marginal employment is not considered to be substantially gainful employment. Marginal employment generally shall be deemed to exist when a veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16(a) (2009). Total disability may or may not be permanent. Permanence of total disability exists when such impairment is reasonably certain to continue throughout the life of the disabled person. Diseases and injuries of long standing which are actually totally incapacitating will be regarded as permanently and totally disabling when the probability of permanent improvement under treatment is remote. 38 C.F.R. § 3.340 (2009). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a) (2009). As a preliminary matter, the Board observes that the term unemployability is not synonymous with the terms unemployed and unemployable for the purposes of determining entitlement to TDIU. A veteran may be unemployed or unemployable for a variety of reasons, but a determination as to entitlement to TDIU is appropriate only when a veteran's unemployability is the result of a service-connected disability. See M21-MR, Part IV, Subpart ii, Chapter 2(F)(24)(c). The Veteran's service-connected disabilities include PTSD (70 percent disabling, effective); type II diabetes mellitus (20 percent disabling); gunshot wound scars, right humerus with retained foreign body (10 percent disabling); and bilateral hearing loss (non-compensably disabling). The Veteran's combined disability evaluation was 70 percent from March 19, 2003, 100 percent from April 11, 2005, and 80 percent from June 11, 2005. Thus, the Veteran meets the minimum criteria for consideration of TDIU. See 38 C.F.R. § 4.16(a). Resolving all doubt in the Veteran's favor, the Board finds that the preponderance of the evidence supports a finding of entitlement to TDIU in this case because the evidence is in relative equipoise. Here, the central inquiry is whether the Veteran's service-connected disabilities alone are of sufficient severity to preclude him from obtaining and maintaining substantially gainful employment. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In this regard, the Board notes that there are competing medical opinions in this instance offering different conclusions as to whether the Veteran's service-connected disabilities preclude him from obtaining and maintaining substantially gainful employment. While the Board may not reject a favorable medical opinion based on its own unsubstantiated medical conclusions, see Obert v. Brown, 5 Vet. App. 30, 33 (1993), the Board does have the authority to "discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence." See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In evaluating the probative value of competent medical evidence, the United States Court of Veterans Appeals for Veterans Claims (Court) has stated, in pertinent part: The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicator . . . . Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). A physician's access to the claims file and the thoroughness and detail of the opinion are important factors in assessing the probative value of a medical opinion. Prejean v. West, 13 Vet. 444, 448-499 (2000). However, the Court in the past has declined to adopt the "treating physician rule," which would give the opinion of a treating physician greater weight in claims made by the Veteran. See Guerrieri, 4 Vet. App. at 471-72; Van Slack v. Brown, 5 Vet. App. 499, 502 (1993). On one hand, the December 2008 and March 2009 VA C&P examination reports concluded that neither the Veteran's service-connected PTSD nor his diabetes mellitus nor his shell-fragment wound residuals would preclude him from obtaining and maintaining gainful employment. In support of this conclusion, these VA C&P examiners noted the following: (1) the Veteran had no serious functional impairments of daily life resulting from the service-connected PTSD in part because of his supportive spouse and access to the Internet, both of which helped the Veteran to partially adjust to impairments he might experience as a result of triggers; and (2) the Veteran's diabetes mellitus, without complications, was an essentially asymptomatic disorder while the shell- fragment wound residuals did not result in significant neuromuscular dysfunction. On the other hand, the October 2007 VRE examiner concluded that the Veteran's PTSD (along with the other service- connected disabilities) impaired the Veteran's ability to work. The service-connected PTSD, in particular, resulted in difficulty interacting with others, crowd avoidance, flashbacks, and difficulty sleeping. The examiner further concluded that the Veteran's PTSD, among other service- connected disabilities, impaired the Veteran's ability to prepare for, obtain, or retain employment consistent with his abilities, aptitudes, and interests. Moreover, the examiner noted that the Veteran, as a high school graduate, possessed "marginal" skills for direct employment. He also lacked post-high school education and/or training which resulted in the Veteran's inability to qualify for suitable stable employment. Although the Veteran was at one time employed in the heating and air conditioning and graphic design businesses, the examiner pointed out that the Veteran lacked significant "transferable skills." Additionally, the Veteran's skills in the heating and air conditioning business were outdated and would, according to the examiner, require re-training, while the labor market did not permit the Veteran to continue with graphic design. The Board also notes that the Veteran failed to pursue VRE training even though he was found eligible for it. There is no indication in the record, however, as to why the Veteran failed to pursue such training. The October 2007 VRE examiner's conclusion was further bolstered by a VA examiner who indicated in a December 2007 addendum that the Veteran was incapable of employment due to psychiatric disability from PTSD symptoms. Where, as here, there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the Veteran. Thus, resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran is entitled to a total disability rating based on individual unemployability and this claim is granted. In reaching these conclusions, the Board has applied the benefit-of-the-doubt doctrine. 38 U.S.C.A. 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1991); Alemany v. Brown, 9 Vet. App. 518 (1996). Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2009). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the Veteran is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court held that, upon receipt of an application for a service connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the Veteran with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection. The Veteran should also be informed that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. With regard to the Veteran's initial rating claim for PTSD, the Veteran is challenging the initial evaluation assigned following the grant of service connection. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the Board finds that the Veteran's claim has been substantiated, additional notice is not required. The Board also finds that all of the relevant facts have been properly developed, and that all available evidence necessary for an equitable resolution of the issue has been obtained. The Veteran's service treatment and post-service treatment records have been obtained. The Veteran was also afforded multiple VA examinations in connection with the current PTSD claim. Accordingly, the Board finds that VA has complied, to the extent required, with the duty-to- assist requirements found at 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c)-(e). With respect to the Veteran's claim of entitlement to TDIU, the Board is granting in full the benefit sought on appeal. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. ORDER An initial evaluation in excess of 70 percent for PTSD is denied. A total disability rating based on individual unemployability is granted, subject to the law and regulations governing the payment of monetary benefits. ____________________________________________ S.S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs